LHIN Leads/Health Service Provider Advisory Group Summary of Assess and Restore Initiatives 2015/16

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1 This document provides a high level description of the Assess and Restore initiatives that were completed in each LHIN with Assess and Restore funding. This summary was developed as a repository of information about the initiatives in order to support knowledge translation. Summary of Key Messages and Lessons Learned Proactively identifying at-risk older adults and providing timely access to restorative services across the care continuum is crucial to avoiding a decline in function and potential permanent loss of independence. Primary care has been identified as an important participant in providing a proactive Assess and Restore approach to care, and in managing the complexity of frail older adults in the community. Building staff competency and expertise in geriatrics is an essential component to the success and capacity of A&R initiatives. More education is necessary for community partners in order to understand the impact of geriatric syndromes on functional decline, and the benefits of a comprehensive geriatric assessment and treatment in the prevention of functional decline. Knowledge exchange opportunities have been imperative in learning from the success and challenges of other organizations. Implementation of Assess and Restore approaches to care across the province has highlighted the inconsistency of specialized geriatric services resources in various communities. Successful implementation must focus on leveraging regionally available resources. Although access to a comprehensive geriatric assessment in order to accurately assess the needs of the patients has been helpful, use of a Nurse Practitioner with gerontological expertise has been highly successful. The availability of rehabilitation services 7 days a week provides ongoing intervention that prevents deconditioning, maintains functional gains and keeps the planned discharges on track. Clear link to the integration of Assess & Restore with other system initiatives (E.g. Senior Friendly Hospitals, GAIN, GEM) is imperative to maintain momentum of positive results. In-home A&R care with a focus on functional enhancement that is goal oriented resulted in better health outcomes, significantly improved patient satisfaction and an increased ability to independently complete activities of daily living (ADL). For many high-risk seniors in the hospital setting (including ED and acute care), the availability of an appropriate mix of targeted Assess and Restore services has led to: increased functional status reduced LOS/expedited discharge to the community decreased rate of conversion to ALC reduced premature institutionalization/ltc demand reduced return visits to the ED or readmissions to hospital 1 P age

2 CEN Enhancing Assess & Restore Capacity within the Central LHIN Screening Tool Adoption Enhanced Service Delivery Community Service Delivery (Home-based) The overarching objective of both partners is to focus on enhancing services to high risk seniors in the North York Central region, with the goal of intervening and delaying the loss of functional ability. The combined goal of the in-hospital and inhome therapy enhancements was to reduce the hospital length of stay, as well as to test an alternative to the transfer of patients to a specialty rehabilitation hospital or convalescent care facility where possible. The Central CCAC developed an A&R Home First pilot project and partnered with NYGH to develop and test a new model of Care Coordination that follows A&R patients across care settings (i.e. from in-patient hospital care through in-home and community care provided post discharge). This approach reduces unnecessary hand-offs, transitions of care and assessments, and increases continuity of care for patients and families. NYGH provided standardized rehabilitation services on acute inpatient units to frail seniors who meet the A&R target population definition. This program includes weekend mobility to ensure patients maintain functional gains while keeping planned discharges on track. The implementation was conducted in three phases: 1. Screening and identification of patients who are currently designated as alternate level of care (ALC) awaiting placement in a specialty rehabilitation hospital The availability of rehabilitation services 7 days a week provides ongoing intervention that prevents deconditioning, and prepares the patient for discharge and subsequent rehab follow up. Feedback from physicians and care team members on providing this level of service has been positive, and early qualitative results indicate patients are maintaining physical/functional status. Patients that are discharged home with CCAC A&R services have benefitted from a dedicated CCAC Care Coordinator assigned to follow the patient from inpatient care to inhome care. This single point of contact facilitates a seamless transition for patients into the community following their hospital visit. Inter-professional meetings involving staff from NYGH and the CCAC, and A&R patients and families has facilitated warm handoffs and proved to be very beneficial in collaborative care planning. The in-home component of the A&R program has been shown to be effective with 82% of clients stating their goals were achieved, as well as 2 P age

3 or convalescent care. 2. Screening and identification of patients admitted to Medical and Surgical beds that are at risk of becoming ALC. 3. Screening and identification of patients that present to the Emergency Department and whose admission could be avoided through direct referral to the CCAC. All three phases utilized a CCAC-led A&R Home First approach that provides enhanced rehabilitation services in the community to support patients discharged from hospital in regaining their baseline functional status. Additional supports in the community are provided following hospital discharge, including enrolment in NYGH s Geriatric Day Hospital or alternative senior s day programming within close proximity to the patient s home (where appropriate). significant improvements in functional ability outcome measurement tools, and on the Health-Related Quality of Life scale. Effectiveness of the inpatient component of the program is more difficult to evaluate due to challenges tracking physical functional progress within the short inpatient duration. An assessment tool will be piloted in 2016/17 to assess clinical efficacy of the A&R program for the inpatient stay. Sustainability plans are continuously under review as more results and direction become available. It is critical to determine how to continue to support the A&R project, as patients discharged at a high level of physical function and independence supports effective discharge planning in acute care and smooth transitions to home and community. Patients and caregivers have shared positive feedback regarding the program in supporting them to regain independence. 3 P age

4 CE Assess and Restore Mobile Team Screening Screening Tool Adoption Assessment Assessment Tool Adoption & Care Coordination Tool Navigation & Placement Standardized Program Criteria Interventions Best Practices Adoption, Enhanced Service Delivery, Geriatrics Training & Transitions of Care To target early screening and standardize geriatric assessment, facilitate navigation, implement an individualized comprehensive plan of care and coordinate transitions to the next most appropriate level of care. The RMH Assess and Restore Mobile (ARM) Team concept is outcome based, patient focused care that promotes early identification and targeted standardized assessment, coordinated navigation, and individualized interventions for those seniors screened and assessed at risk. The model connects and ingrains the in-reach of the City of Kawartha Lake Community Geriatric Assessment and Intervention Network (GAIN) team, Community Care Access Centre (CCAC), primary care, and other community services. The ARM Team will assess the inpatient clients regardless of bed designation and will focus on this frail senior/medically complex patient population in acute care and consult in post-acute care. The team will augment the use of evidenced based geriatric assessments and individualized interventions to support both the in-hospital management of geriatric syndromes and the successful transitions home or other destination in the care continuum. Treatment will be aimed at increasing strength, mobility, and Visibility of the role and function of the team required constant emphasis to the front line staff and the interdisciplinary team. Role clarity, referral criteria, and collaboration with the existing inpatient team were also required. The value of 1:1 consultations with individual team members (especially physicians) related to function and role of team and strategies was apparent. Earlier emphasis on building on the foundation of geriatric education would have been helpful. The role of pharmacy in medication reconciliation and the follow-up with the MRP and PCP was very valuable. Development of strategies required to retain qualified staff for one time funding projects was required. ARM team involvement is extremely valuable to patient flow related to high risk for discharge. Having the ARM team to identify needs and facilitate hospital and community resources was very valuable. Implementation of a communication 4 P age

5 CE Northumberland Hills Hospital Assess and Restore Intervention Proposal Multielement Direct Access Priority Process To provide comprehensive gerontological assessment, identification of geriatric syndromes and interventions for those older persons who are frail high risk seniors; therefore being most at risk both in hospital and in the community. To provide early screening and standardized geriatric assessment, facilitate navigation, implement functional ability, with the goal of returning to the community or the next most appropriate level of care. The ARM team will target early screening and standardized geriatric assessments, facilitate navigation, implement an individualized comprehensive plan of care, and coordinate transitions to discharge home or the most appropriate level of care. The NHH Assess and Restore Intervention model of care provides comprehensive gerontological assessment, the identification of geriatric syndromes, and intervention for frail at-risk seniors. The focus of this initiative is to prevent the cascading effects of health decline that often result in more complex health needs, or failure of the person to live at home. NHH Assess and Restore Intervention is led by a Nurse Practitioner- Gerontology who is progressively developing expertise in gerontological best practices, tool with primary care for ongoing follow-up and the ability to utilize phone follow-ups post discharge was useful. It is important to streamline and link GAIN patient to GEM to ARM and back to GAIN. A standardized approach to working with patients with delirium is needed. The value of standardized comprehensive assessments was evident. Medical comorbidities and geriatric syndromes must be addressed together in order to create efficiencies and best practice in gerontology. This management leads to deeper resolution to the chronic illness/frailty situation. Dedicating the resource of the gerontological NP is critical. NP led A&R initiatives, in collaboration with the GEM nurse, maximized efficiencies, capacity development, and patient outcomes. Evidence that a Gerontological NP led A&R is ideal for primary care physicians, front line, and the broader health care. This service removes the 5 P age

6 an individualized comprehensive plan of care and coordinate transitions to the next most appropriate level of care. complex gerontological assessments, and an understanding of gerontology syndromes and interventions. burden for a deeper gerontological assessment from the primary care physicians and introduces gerontological knowledge and research data related to care of frail older persons. Utilizing comprehensive gerontological assessments to support care based in geriatric syndromes, effectively targets the frail and functionally declining population. This is evidenced by the number and type of geriatric syndromes observed in this population. 87% of A&R patients had 4 to 10 geriatric syndromes. Efficiencies with geriatric syndromes will diminish use of healthcare resource cost over time and maintain people living in the community. Some geriatric syndromes presented with very high incidence (i.e. mobility/ falls at 97%, pain at 70%, mental health at 68%, functional decline at 57% and incontinence at 47%). A focus on polypharmacy as a geriatric syndrome is pivotal to minimizing other geriatric syndromes, which if left unmanaged would create other health 6 P age

7 crises in the frail population. 49% of A&R admissions were direct admissions from the community via the ED to post-acute beds. This is evidence of gerontological best practice and avoidance of acute care bed usage; and provides necessary service opportunities and flow of patients within the hospital and healthcare system. Management of geriatric syndromes to improve LOS, readmission rates, patient flow, and ALC rates. A new definition of high risk population for increased frailty is occurring through geriatric syndromes data. Management of a cluster of geriatric syndromes will prevent increased healthcare costs and maintain older people living in their communities. Current data creates a foundation for a new screening assessment tool for A&R. This tool will be based on the number of geriatric syndromes, type of geriatric syndromes, and /or intensity. Current data and service provision provides opportunity to define "restorable" in this population. 7 P age

8 CE Assess and Restore - Scarborough hospital virtual ward Assessment Formal Partnerships Navigation & Placement Formal Partnerships Interventions Enhanced Service Delivery Transitions Home Transitions of Care To establish collaboration between social workers and therapy teams and to enhance program operations and performance. A specialized community based ambulatory rehabilitation service to patients discharged from Acute Care for Elders (ACE). Components of the daily program include: 1) Therapeutic Exercise; 2) Functional Teaching; 3) Complementary Activities; and 4) Peer Support Linked with Virtual Ward to pull patients into the community. The evolution of the Needs Identification and Stratification Tool was essential to broaden the scope of discharge options for the health care team and to have more tailored pairing of patient and program. The tool enabled the health care teams to identify highly complex patients that may benefit from Health Links and are linked with hospital and or community based GAIN teams for further assessment and intervention post discharge. Utilizing a LEAN methodology to develop the tool in collaboration with community partners helped to establish the process maps across the continuum of care from acute care to community. Utilizing electronic tracking systems would support sustainability efforts and easier review of performance metrics. A variety of clinical indicators are tracked and additionally, the ERP is participating in the upcoming pilot project through the RCA to assess: Patient Self Report Tool & In Clinic Assessment of Function Patient Experience Measure tool 8 P age

9 CE CATCH Program Screening Screening Tool Adoption Transitions Home Transitions of Care The purpose of the CATCH program is to improve patient flow by reducing length of stay and readmission rate through a multidisciplinary approach in post discharge risk assessment and intervention. Patients are referred to ensure they have a safe discharge home from hospital. The CATCH program is an outpatient program that is delivered by an interdisciplinary team of health professionals. There is also a linkage to our general internists. Patients are first assessed by a PT, who develops an individualized reconditioning program for the patient. Through reconditioning, the PTA helps to reach optimal physical functionality and independence. The registered practical nurse assesses the patient s discharge milestones, and will do a risk assessment to address aspects of the patient s discharge that still require follow-up. The nurse supports the patient in following discharge instructions, addressing risk factors and reinforcing health teaching that is focused on understanding your condition and how to prevent deterioration. A key lesson learned is the significant impact a post-discharge program can have on keeping patients safe in the community. CATCH helps ensure patients are connected to community supports by monitoring patient s risk factors and providing appropriate interventions as needed. These risk factors can leave patients susceptible to readmission to hospital. Many can be managed with ongoing support during this critical transition from hospital to home. Among this population, the most significant risk factors addressed through the CATCH program have been falls, medication safety, and discharge instruction compliance. In terms of linking with the community, the program bridges the gap between the inpatient hospital stay and independent living in the community, ensuring patients do not fall between the cracks to prevent readmission. 9 P age

10 CW Home Independence Program (HIP) Interventions Community Service Delivery (home-based) To provide support to patients experiencing functional decline and/or limitations in their ability to independently care for themselves. The HIP was offered to all eligible seniors throughout the entire CW LHIN. This program serviced eligible patients from both community and hospital. Early identification and program implementation decreases the risk of further deterioration thereby decreasing dependence on the healthcare system. We know that falls are a major contributor to ED visits and readmissions. This program contributes to a reduction of injurious falls in the home. The program demonstrates that early intervention with specialized homecare services can have a significant impact on a patient s recovery and reduces the likelihood that they will rapidly decline. Outcomes show improvement of functional ability among seniors as noted through improved timed up and go measures and decreased rates of falls. Participants also showed a significant decrease in risk for presenting at ED, while simultaneously increasing their engagement with PCP. The data suggests the efficacy of patient focused, goal oriented and individually tailored care resulted in significantly improved patient satisfaction, better health outcomes, and an increased ability to independently complete the activities of daily living (ADL). Patients reported that their overall pain levels were lower, their emotional wellbeing improved, and their ability to accomplish their goals was greater. Standardized assessment and early identification approaches have been successful due to integrated care 10 P age

11 CHAM Clinical Patient Flow Algorithm from Acute to Sub-Acute Care Navigation & Placement Formal Partnerships To formalize standardized and shared protocols for A&R interventions for managing the placement of targeted seniors into post-acute care beds from acute care. The project enabled the expansion of the Clinical Pathway Flow Algorithm. These new resources collaborated with existing resources at the subacute facility to improve transitions for frail seniors. This Clinical Flow Algorithm improved wait-times and transitions to sub-acute beds and benefited patients in the Ottawa region through reducing the time for 80% of the consults to be seen to a coordinator approaches as noted through primary care alignment and the integrated acute care coordination models. Smooth transitions from acute care into the HIP model and then to independence in the community are monitored and overseen by an integrated interprofessional team. Technology improves efficiencies in communication and care planning for upcoming years. Providers utilize personal computer video conferencing as a communication enabler, which also includes linking with the primary care provider thereby ensuring a strong team based care approach. The program continues to benefit from telemedicine approaches. Expansion of the Clinical Patient Flow Algorithm to other hospital partners has been successful through the collaboration of the stakeholders committed to ensuring success. Physician and staff working on the acute care units have provided very positive feedback regarding the streamlined one-stop shopping approach. Once a patient is identified 11 P age

12 CHAM Rural Assess and Restore in Champlain LHIN Interventions Community Service Delivery Transitions Home- Transitions of Care To pilot a flexible rural A&R community program that leverages current services (e.g., RGP of Eastern Ontario, GEM services, CCAC care coordination services) and purchasing services to address system gaps. The model would support diverting high risk seniors from unnecessary hospital utilization (unnecessary ED visits and hospital admission). target of 48 hours. In addition, the program improved the time to acceptance to the program and discharge of the patients to the subacute beds. This project developed and implemented a flexible model of care and navigation to identify and assess high risk seniors. It combines the Geriatric Emergency Management (GEM) Nurse and Community Geriatric Outreach Assessor roles - to improve the access to specialized geriatric and community support services in the Carleton Place area. The effectiveness of the Assessment Urgency Algorithm (AUA)/ Emergency Department (ED) screener in the Emergency Department was also implemented as a screening tool to assist in identifying seniors at risk. This project improved coordination of services and continuity of care in a it is the triage team that completes the referral form and determines most appropriate destination, simplifying navigation and reducing workload for physicians. It is expected that automating this activity with e-referral will further speed-up the process and invite transparency. Moving toward e- referral and including smaller hospitals will be important to expanding this endeavor. Based on the extensive evaluation process completed, which included both quantitative and qualitative results, the rural A&R pilot project was extremely successful. The combined role of GEM/Geriatric Assessor, a role not previously implemented, proved to be a beneficial one. In particular, the continuity that the role offered to high risk seniors was recognized immediately by primary care providers as valuable. ED staff & physicians felt more confident in discharging frail, high-risk seniors knowing that the appropriate follow up services were in place. Learnings included the value of recruiting the right person with the right skills and knowledge of the rural 12 P age

13 number of ways. It increased access to Specialized Geriatric, Community Support Services, Service level agreements and Going Home services to provide patients timely access to these services. Stronger partnerships, and more consistent referral processes, were created with Community Support Agencies, Lanark Mental Health Geriatric Psychiatry Outreach, and the CCAC. A feedback loop was provided to local family physicians regarding rostered patients receiving any of these services. environment and resources. In terms of improved access to specialized geriatric services and community support services, outcomes demonstrated the success of the pilot. For example referrals to the CCAC and the Going Home Program doubled and proved instrumental in maintaining high risk seniors in their homes. Patients accessing the geriatric clinic doubled and the hospital significantly improved functional capacity for all attendees and served a new segment of the high risk population. Testing of the AUA as a screening tool to identify high risk seniors demonstrated that the tool appears to be more sensitive than the current tool used in the region. In addition, the clinical pathway developed to identify resources based on AUA score proved to be a valuable resource which contributes to sustainability and transferability of the program. An important system level outcome of the pilot is a possible impact on Carleton Place Hospital s overall ALC rates. The findings were that the percent of ALC patients decreased by 31% and percent ALC days decreased 13 P age

14 CHAM AUA Screening Tool Adoption Assessment - Assessment Tool Adoption The project will focus on training, education for screening tool users, and engage system providers. Additionally, The RGPEO and CCAC will work on mapping out the Clinical Pathways based on the scores of the AUA. The project focused on the training personnel from the Champlain CCAC, Community Support Services sector, and Regional Geriatric Program of Eastern Ontario for the adoption of the AUA. Mapping of the clinical pathways was completed, specific to Champlain, based on a client s AUA score. Collaboration among project partners allowed the review of referral processes and established new/refined processes for the pilot project. Formal links were made with the Personal Support Services Early Adopter project to integrate the use of the AUA into client service planning. A communications script was developed and used by both CCAC and CSSA staff. Evaluation of the implemented processes and tools developed for the project was performed by the clinical lead. by 29%. If we then apply the lower ALC rates of the pilot to the pre-pilot sample of 448 patients, there would have been 25.4 fewer cases admitted that became ALC and fewer ALC days. It was determined that an e-referral process with transfer of completed AUAs is valuable to the receiving CSS agency. The agencies are also reporting that the Champlain AUA pathway document was useful for follow up visits and engagement with clients and caregivers once a relationship was established. Further exploration is needed to discuss referrals to other organizations. Of interest, it was determined that educating clinical staff on the worth of a geriatric assessments, the importance of early intervention, and the way in which requests for equipment by clients/caregivers may be an indicator for both specialized geriatrics and therapy services. 14 P age

15 ESC Seniors Mobile Assess and Restore Teams (SMART) Interventions Enhanced Service Delivery To increase access to and the capacity of Assess and Restore interventions by allied health team to frail seniors admitted to acute care settings. For 2016/17, the previous base funding allocations have been pooled (i.e. previous Activation funding plus the new A&R funds) and work to standardize these programs into a Seniors Mobile Assess and Restore Team (SMART) approach has been initiated. The SMART project continues to provide ongoing focus on the risk of seniors loss of independence because of hospitalization and acute illness, and highlights the need for a broad Assess and Restore philosophy across our organizations. Convened an Assess and Restore Working Group to manage the enhanced service delivery project and collaborative planning and coordinate standardization of project implementation. Further standardization of data collection amongst the organizations is needed and will occur for We have now refined the data reporting sheet for a more streamlined and standardized process for this coming year. There is growing appreciation of the functional impacts on activities of daily living when acute illnesses occur in older adults, and the benefits of early engagement of PT and OT expertise. Early opportunities to recognize restorative potential, and identify patients for ongoing rehabilitative care have been realized. Utilization of electronically available data submitted by organizations to the DAD was found to be possible. This avoided utilization of front line staff for data collection which would have taken away from direct patient care time. Overall, data collection is challenging with limited resources and the significant pressures on organizational Decision Support teams. The mobile aspect of the approach is very beneficial and not limiting to a specific geographical location. Availability of GEM nurses on the inpatient units (only at one site) continues to provide enhanced geriatric care expertise with the care teams which facilitates identification of geriatric syndromes. Geriatric 15 P age

16 HNHB Seniors Mobile Assess and Restore Teams (SMART) Interventions Enhanced Service Delivery The SMART model aims to provide hospitalized seniors that have restorative capacity with access to a mobile dedicated interprofessional teambased integrated Mobile, rehabilitative care provided in hospital for frail seniors who have experienced functional decline and are at risk for further functional decline. The SMART team develops and provides an intensive restorative program that targets individuals specific recovery needs with the goal of earlier discharge home. conditions are appropriately managed in a timely fashion which assists in the prevention of functional decline early in their acute care stay. In larger sites, the capacity of the GEM RN to leave the ED is not available, and the need for Clinical Nurse Specialists in Geriatrics on medical units continues to be recognized. The ability to have rehabilitative care providers in the ED has enhanced the GEM RN role and resulted in patients being able to access an inpatient rehabilitation bed directly from the ED - at one site. Allowing for 7 days per week service delivery even on weekends has been helpful. Funding supports efforts to reduce ALC, facilitate discharge planning and enhances the necessary rehab HR needs. For seniors who are high risk, SMART should be a standard of care provided in parallel with acute medical care (ED/Acute) at all hospital sites. A mobile assess restore model has the potential to reduce functional decline. 16 P age

17 model. SMART Improves the Patient Experience Through Quality, Integration & Value Improves Quality of Care Improves access to rehabilitative care (Increases capacity) Prevents functional decline Improves function as measured by the Barthel Activities of Daily Living Index Promotes discharge home Decreases need for post-acute rehabilitative care Integrates Services Eliminates transition points, associated Individuals are identified and receive care in the emergency department (ED) and acute medical units. Individuals are screened within 24 hours of ED arrival with the Early Intervention Screener (EIS); individuals who screen positive, are screened for SMART. Individuals begin the SMART interventions within 48 hours in parallel with acute medical care. The SMART intervention includes two funded full time equivalents of rehabilitative care staff (i.e. occupational therapists (OT), physiotherapists (PT), OT assistants and PT assistants). The core SMART team members work together with in kind interdisciplinary team members to deliver a SMART rehabilitative assess restore philosophy of care 7 days a week. Additional SMART team members include social workers, nurses, and pharmacists. Individuals benefit from receiving rehabilitative care in parallel with acute care. The majority of individuals who receive SMART in acute care are able to return home. There is an increase in function pre and post SMART as measured by the Barthel Activities of Daily Living Index. The majority of individuals who receive SMART do not require a bedded level of post-acute rehabilitative care. Individuals who receive SMART and require post-acute bedded rehabilitative care require a shorter length of stay. A subsequent systems impact is observed related to the number of days individuals are waiting for postacute rehabilitative care beyond those enrolled in SMART. There is a potential significant cost avoidance related to the decreased LOS required within post-acute rehabilitative care following SMART; the decreased need for bedded rehabilitative care for individuals who 17 P age

18 referrals, assessments and wait times Improves flow to post-acute rehabilitative care Rehabilitative care provided in parallel with acute care Provides the right support at the right time Adds Value Improves the patient experience Decreases length of stay (LOS) Decreases need for bedded rehabilitative programs 1. Cost avoidance have received SMART and the decrease in acute ALC to LTLD bed days. Results as follows: SMART Improves the Patient Experience Through Quality, Integration & Value Patient experience: Please refer to the SMART video: Voices in the Community. SMART participant story from the NHS. Improves Quality of Care 4028 Individuals served 27% increase in function as measured by pre and post administration of the Barthel activities of daily living index 83% discharged home 8% require post-rehabilitative care. Integrates Services 20% decrease in the number of ALC days for patients discharged to Complex Care Low Tolerance Long 18 P age

19 Duration (LTLD) which includes complex care restorative, assess restore and slow stream rehabilitation within the HNHB LHIN. 20% decrease in ALC to LTLD noted in HNHB LHIN level data from 12 month period from fiscal year 2014/15 compared to the same 12 month period fiscal year for the six SMART hospitals sites 7373 ALC days for April Mar 2016 compared to 9253 ALC days April 2014 March 2015 (Source: HNHB LHIN level data. 6 SMART hospital sites. Access to care iport). Adds Value: Decreases LOS Average LOS in post-acute care bed for patients with a similar CMG; 26 days Average LOS in post-acute rehabilitative care for SMART patients; 20 days Average difference in LOS between SMART patients and patients with similar CMG; 6 days. 19 P age

20 (Source for LOS 6 hospital site specific SMART reports). Decreases need for bedded rehabilitative care programs 8% require post-rehabilitative care. Cost Analysis The SMART cost analysis indicates a potential cost avoidance for the system associated with the decrease in post-acute rehabilitative care length of stay (LOS) when compared to individuals with a similar case mix group (CMG); the potential avoidance of a post-acute rehabilitative care admission and subsequent LOS; as well as the decreased acute ALC days to Low Tolerance Long Duration days (LTLD). Detailed cost analysis information is included in the Final Report. MH Enhanced Rehabilitation to Support Community Transition step up Transitions Home Transitions of Care To assist clients and their families with the adjustment from hospital to home in a shorter time by providing on-going individualized Patients attending the program are frail and present with multiple chronic and co-morbid conditions. The presentation necessitates 1:1 interventions with regulated health professionals to ensure patient s needs are met in a safe and successful 20 P age

21 programming within an OP setting. manner. A holistic and patient-centered approach is important to the success of the program. Inclusion of caregivers in the program and providing them with education and support is key in enabling better supported patients in the community. Connecting and educating patients regarding the different community supports and services in their area. The ability to refer patients to specialized clinics and working collaboratively with these specialists is important. An interprofessional approach to patient care was beneficial to both the patients and their caregivers. A need for Social Workers is identified as a current gap in the model. Low functioning patients are experiencing a gap in community services once discharged from the program. Wait lists for day programs are reported to be lengthy. Incorporating a variety of outcome measures such as the Berg Balance, MOCA, Pre-driver screen, Boston Naming Test provides an objective 21 P age

22 MH VON SMART In- Home program Interventions Enhanced Service Delivery To increase services to clients who would not otherwise have been accepted into the A&R program due to the added complexity of their needs. The program focused on two populations; those from hospital and those from the community utilizing the evidence based, nationally accredited SMART program. The upstream approach is for frail seniors. Frail Seniors who were identified as meeting the established criteria received in home 1:1 exercise sessions to increase their strength, mobility and functional abilities. The program consists of 15 gentle exercises geared towards the frail elderly and other vulnerable individuals that have experienced a recent loss of functional abilities following a medical event or decline in health. means of communicating with both patients and their caregivers on the progress. Client engagement is important to improve compliance with the program. Encouraging clients to be accountable to continue with the exercises even when a clinician isn t present. The AUA has been very beneficial in correctly identifying appropriate referrals for the program. Using the Time-Up and Go (TUG) pre and post exercise outcomes showed a variety of results. It is important to remember the TUG is a measure to assess mobility associated with falls and additional performance measures will be needed to truly identify other functional gains such as the BERG Balance Scale, Barthel Score, Tinetti and the 30 second sit-to-stand test. A portion of the funds was used to develop an elearning module on depression that supports provincial knowledge transfer initiatives to build capacity and improve quality in the care of frail seniors. 22 P age

23 MH MH CCAC Rapid Recovery Program Interventions Community Service Delivery To enable safe and timely discharge from hospitals for patients waiting for in-patient rehabilitation or for those patients who require enhanced rehabilitation from a multi-disciplinary team to maintain, improve, or restore to optimum function in their homes. The Rapid Recovery Program at the MH CCAC helps to prevent unnecessary prolonged hospital lengths of stay and admissions to inpatient rehabilitation. The uniqueness of the program is the provision of intensive in-home rehabilitation services during the first 2 weeks post-discharge. The Rapid Recovery Program offers a viable and more cost-effective alternate to patients who may be: Awaiting inpatient rehab while in an acute-care bed. Admitted to inpatient rehabilitation by can be discharged early to resume their rehabilitation within the in-home setting. The program has seen continued growth, with ongoing high rates of referral. Assessment urgency and rehab algorithm scores suggest we continue to see patients within the target group. The program is looking at reconfiguring it in order to target issues such as hospital readmission, patient population, lower than expected Occupational Therapy utilization, and challenges scheduling the intensive physiotherapy services to meet patient preference. Key changes under considering include: introducing Rapid Response Nursing to the care delivery team working with hospitals to create a more direct referral model further defining anticipated outcomes and expected interventions delivered increasing flexibility of service scheduling to address patient and family preference implementing a quality improvement initiative to ensure accurate coding of patients when transitioning off the program 23 P age

24 NE Assess & Restore Collaborative (ARC) Multi- Element Project Direct Access Priority Process Initiative (DAPP) The goal is to develop and test a local process for direct admission to facility based Assess and Restore interventions within the suggested time frames. The project is piloting the Direct Access Priority Process in 2 Hub communities and includes aspects of timely identification and assessment of older adults who meet the criteria for the target population. The goal is to develop and test a local process for direct admission to facility based Assess and Restore interventions within the suggested time frames. Areas of focus are the first 3 elements of the Assess and Restore approach to care Screening, Assessment and Placement/Navigation. Step 1 Early Identification Step 2 Assessment Step 3 Navigation & Placement The ARC project team has identified Essential Elements for DAPP implementation and has developed a checklist to assist in identifying current state readiness. These Essential Elements fall into 6 categories: Local Leadership, Key Stakeholder Commitment, Specialized Geriatric Services, Community-based Pilot Site, Bedded Levels of Rehabilitative Care and Communitybased Levels of Rehabilitative Care. Further alignment with the RCA initiatives is critical for development of infrastructure necessary to support a proactive shift in health care delivery for the target population and beyond. The uptake of RCA and NE LHIN Rehab/CCC Steering Committee rehabilitative care-related information varies significantly by Hub area and health service provider. Knowledge translation is person-dependent and leadership-focused. As a result, initial ARC project implementation required considerable investment in engagement and planning activities to achieve suitable readiness. This project has highlighted the 24 P age

25 NSM Geriatrics Training & Best Practices Adoption Interventions Best Practices Adoption Interventions Geriatrics Training Developing a learning plan in collaboration with providers and in alignment with the RCA s Compendium document that will include: To increase the flow to Assess & Restore facility based interventions this project will: - Increase the number of health care professionals AND skillsets of health care professionals in the care of frail seniors. significant gap in the NE healthcare systems awareness and understanding of specialized geriatric services as an area of clinical expertise and the role of the North East Specialized Geriatric Centre (NESGC) as a Regional Geriatric Program. A geriatric/senior-friendly approach to care is fundamental. Within the different districts and HSPs, there is significant variability in the infrastructure that exists to support and standardize the delivery of geriatric care. For project outcomes to be sustained and spread beyond March 2017, a system-wide, regionally coordinated approach to geriatric care and geriatric rehabilitation delivery is required and should be inclusive of district-level leadership and contextualization. It was challenging to recruit a registered staff person for a shortterm contract position. Significant travel time was involved as the CCP sites are situated in different areas in NSM LHIN this resulted in significant in-direct time. 25 P age

26 Education events On-site mentoring, coaching and support Program planning and implementation As appropriate, policy and procedure development. - Standardize and disseminate leading practices. - Increase the self-management capacity of frail seniors and their caregivers. This local work will also support implementation of transitions of care work stemming from the second NSM LHIN Project, Enhanced SMART & Transitions of Care. It was determined that multiple sites had similar learning needs, i.e. Falls Management. Interpretation of Fall was different from site to site which results in reporting differences. NSM Enhanced SMART & Transitions of Care Interventions- Enhanced Service Delivery Transitions Home- Transitions of Care To increase access to A&R facility based interventions (CCP, ACE). Enhanced SMART and Transitions of Care builds on the current SMART program. Enhanced SMART is designed to support those complex frail seniors with higher intensity needs and increase access to Assess & Restore facility based interventions (CCP, ACE). Seniors Maintaining Active Roles Together (SMART) became operational in NSM LHIN in 2007/08 to serve approximately 1,385 seniors. The SMART program offers exercise classes to community members 55+ who wish to improve their strength, balance and flexibility, regardless of their physical abilities. Enhanced SMART currently offers advanced rehab 2 x 0.5 days/wk to up to 12 individuals per class for a 6-12 week period. Three separate classes/groups per week are hosted. It also provides post discharge followup and monitoring and system navigation. It has been challenging to secure a venue that is cost-free, accessible and has adequate space to hold exercise classes on an on-going basis. Clients being admitted are of higher frailty than originally expected and are admitted into the In-Home program rather than Group, which has increased recruitment requirements to meet the needs of the increased numbers of In-home participants. Preliminary data analysis from the first 21 clients to complete the care in the Enhanced SMART Program illustrates improvement in all qualitative and quantitative outcome measures collected at admission and discharge. 26 P age

27 NW NW Enhanced Service Delivery Thunder Bay Regional Health Sciences Centre (TBRHSC) Navigation & Placement Process Standardization Interventions Enhanced Service Delivery Navigation & Placement- Standardized Program Criteria To reduce hospital admission, length of stay and improve functional status of A&R patients in an acute care setting. The purpose of this project was to improve access to post-acute inpatient services directly from the ED/community. This project was a continuation of the geriatric care coordinator position from the 2014/15 project. The coordinator actively assessed at risk elderly patients from the target population by using standardized tools to identify geriatric syndromes and facilitate care for patients experiencing dementia, depression, delirium, falls, mobility issues and frailty. The coordinator worked closely with the gerontologists, rehab staff and community partners to provide care coordination for safe and reasonable discharge. The purpose of this project was to improve access to post-acute inpatient services directly from the ED/community by standardizing actives and processes involved in accessing in-patient rehab beds. Direct access to these services will avoid inappropriate admissions to the acute care facility; thereby The project showed great potential to reduce length of stay, improve functional ability and continue safe discharges back to home. Standardized tools were used to better screen at-risk individuals. The geriatric coordinator worked closely with other professionals and was an integral part of the hospital s A&R team. Based on the evaluation and engagement with the health service provider, this role would be continued in the next fiscal. Overall, implementation of this initiative demonstrated improved patient outcomes and an opportunity to maintain gains. From those enrolled, 42% were discharged home, 39% were discharged to post-acute services. Stakeholder engagement and knowledge sharing happened between the rehab and acute care hospitals. A process for community to rehab admission was developed. Education was provided to CCAC case managers. Formalization of referral pathways from ED to rehab are being considered in the coming months. 27 P age

28 NW Enhanced Service Delivery (Lake of the Woods District Hospital) Interventions Enhanced Service Delivery To facilitate earlier and more intensive rehabilitation intervention on the acute care floor, specifically for activities of daily living. decreasing acute care utilization and improving patient outcomes by providing relevant care in the most appropriate way. In addition to this, the project goal was to review all rehab/ccc services within the North West LHIN and develop a regional integrated service delivery model for rehab services. This project is a continuation of Physical Medicine Occupational Therapist position (0.4) from the 2014/15 project. The therapist has been able to augment positive impacts of the program by introducing rehab services to seniors with restorative potential earlier, improving functional status, resulting in decreasing length of stay and Streams of care concept is being introduced at the post-acute care facility to create ease of access to rehab care. The importance and benefits of having direct admission to rehab beds from ED/community was validated and work will continue to formalize and utilize these processes on an ongoing basis. This is extremely essential to improve patient flow and the overcapacity pressures in the acute care sector. The creation and the implementation of the regional integrated service delivery model will improve access to quality rehab services across the region including direct access to rehab beds. The A&R program has addressed the issue of long wait times and travel to other communities, by providing the means for the small community hospitals to offer a level of service that is comparable to a regional rehabilitation hospital, without the long wait and the need to travel away. The result is a significant improvement in patients functional status and in 28 P age

29 SE Enhanced Service Delivery Interventions Enhanced Service Delivery The intention under the Assess and Restore model is to maximize and enhance bedded facilitating safe discharge back to the community. Specifically, the target population will be supported to enhance independence with activities of daily living through improved basic motor functions. Providence Care will increase assess and restore capacity in Acute care by providing resources to support the operation of 5 additional IP beds at the ability to return to home. In addition, on discharge, these clients have actually had a significantly reduced need for home care services, as patients and families have been enabled to a level of independent functioning. As well, their hospital lengths of stay have decreased as they have improved to a discharge status much faster with the increased treatment. Furthermore, LTC admissions have been prevented through supportive and comprehensive treatment focused on a return to home. Clients of the A&R program are seeing benefits of working with rehabilitation staff and are aware that participation in this program means that they will have greater chance of success at home. Many clients feel the program has become their second chance at independent living. Others describe it as a chance to wait at home for long term care rather than living in hospital for months on end. 29 P age